A Performance Improvement Tool

These Frequently Asked Questions have been compiled by the Performance Improvement Consultative Group (PICG), which consists of representatives of USAID and USAID-funded cooperating agencies. If you have questions or suggestions regarding these questions and the answers, please contact Jim McCaffery by e-mail at jmccaffery@trg-inc.com

1.  What is Performance Improvement?

Performance Improvement (PI) is a process for enhancing employee and organizational performance that employs an explicit set of methods and strategies. Results are achieved through a systematic process that considers the institutional context, describes desired performance, identifies gaps between desired and actual performance, identifies root causes, selects, designs and implements interventions to fix the root causes, and measures changes in performance. PI is a continuously evolving process that uses the results of monitoring and feedback to determine whether progress has been made and to plan and implement additional appropriate changes.

2.  What is the goal of PI?

The goal of Performance Improvement is to solve performance problems or realize performance opportunities at the organizational, system, process and employee levels in order to achieve desired organizational results.  The overall desired result in our field is the provision of high quality, sustainable health services.

The PI process is most likely to achieve its goal and desired result when the following factors are present:

• Managers and staff from the organization actively participate in all stages of the PI methodology and change process.
• PI practitioners identify and build on existing performance assets and successes as well as fix performance problems.

3.  Why is PI important?

The adaptation and systematic application of PI to expanding access and improving the quality of reproductive health services in low resource settings is an important contribution to the field.  In an era marked by increased emphasis on results and greater accountability, PI is dedicated to improving performance to bring about those results.  PI has contributed clear and simple models, assessment tools, methods, practices, performance standards and measures.

While the adaptation of a PI framework and tools to a different context may be new, working to improve performance in the workplace is not new. A variety of disciplines have long focused on ways to improve performance in the workplace (e.g., organization development, management, industrial engineering).

4.  How is PI applied in an organizational setting?

Performance Improvement methodology may be applied to large organizations, work processes and to units or teams or at the level of a group of performers.  The overall performance of an organization is the result of performance at all of these levels.  Each level and component of an organization is connected to other components.  Therefore, to create real, sustained improved performance, we must take a systems approach by working at different levels at the same time, and recognizing the ways in which interventions at one level affect or are supported by interventions at different levels.

For example, the root cause of a performance gap for a group of rural Reproductive Health providers may be outdated sectoral policies, the lack of clear organizational strategic direction, regional supply problems or unclear job expectations at the site level.  Thus, while the initial unit of analysis for the performance needs assessment may be at the provider level, the ultimate solutions may require interventions at different levels (e.g., sectoral reform or an organizational strategic planning process).

5.  What are some examples of frequently used interventions that can be used to improve performance?

An intervention is an activity, process, event or system that is designed to improve performance by fixing the root cause of the gap between desired and actual performance.  There is a wide array of interventions that can be used to improve performance.  Some examples include the following:  developing organizational mission and strategies to achieve it; improving inter-unit teamwork; setting and communicating clear job expectations; designing and implementing appropriate performance feedback systems; creating job aids (e.g., to track supplies, to remind managers about effective ways to run meetings); training; building monetary and non-monetary incentive systems; developing and implementing polices, procedures, guidelines and standards; developing simple, non-costly ways to recognize good performance; providing supervisors tools for participatory problems solving, and training; change management, and so on.

Performance needs assessments typically uncover problems in more than one performance factor, and will provide compelling data to help prioritize the most needed interventions (those that will have the largest impact for the lowest cost).

6.  How will the PI process help organizations (including Collaborating Agencies) work together?

When working in large-scale reproductive health programs in low resource settings, it is likely that the reasons for performance gaps and the appropriate interventions to improve performance will require several organizations or partners.  The PI framework will provide a shared definition, framework, approach and many of the tools that will enable organizations to work more easily together to fix performance problems.  Conducting the performance analysis jointly, whenever possible, helps set in motion a collaborative process among partner organizations and assists in defining each partner's particular role in addressing performance issues.  Depending on the expertise and specialties of particular organizations, each will use particular methods and tools they have adapted or developed to carry out PI.

It is also likely that their primary targets for interventions may differ.  One organization may, for example, apply PI to improving a management system, while others may apply it to improving the performance of Traditional Birth Attendants. With a shared framework we can more easily collaborate with each other, especially at the local level, as we implement PI in order to leverage the best skills and expertise different organizations bring to the shared goal of improving performance. 

7.  How do I explain PI to ministries of health, NGO’s and missions?

The purpose of PI discussions with stakeholders is to offer a powerful approach to improve performance and get desired results in a cost-effective manner. Discussions with clients and stakeholders should include language and concepts that ‘fit’ the context, and employ as little jargon as possible.  If the situation calls for an explicit discussion of PI as an approach, then we recommend use of the model and framework that has been developed by the PICG, as doing so will present a consistent message from all partnering organizations.

8.  What is the relationship between PI and training?

Training is one of many PI interventions. Often in the past, training has been the only intervention applied to performance problems. By contrast, Performance Improvement acknowledges a variety of factors that can result in poor performance.  Some examples include unclear job expectations, lack of feedback on performance, dysfunctional management systems, inadequate equipment or supplies and lack of knowledge or skills. These factors demand varied interventions.

9.  What is the relationship between Quality Improvement and PI?

There is an ongoing debate and discussion about this issue.  This response represents our latest thinking about this question. 

The origins and orientation are somewhat different. Quality Improvement (QI) efforts have their roots in engineering, statistics and management while PI has its origins in the behavioral sciences.  QI asks: What steps can we take to make sure we do the right thing right? PI asks: What is needed to improve performance?  Ultimately the approaches are complementary since, to provide better client services, we ultimately have to grapple with how performers are doing their work.

While their origins and orientation may be different, there are significant similarities between the QI and PI models. Both are cyclical problem-solving processes. Both advocate the establishment of standards and the continual quest to meet those standards. Both seek to establish the root causes of identified problems. Both identify and select appropriate actions that are intended to address performance problems. Both QI and PI seek the same ends: high quality products or services. Both models draw from the same tool box, although the use of the tools may vary. The approaches are complementary and the strengths of each should be brought to bear in implementing reproductive health interventions.

10.  How does PI relate to Maximizing Access and Quality (MAQ)?

Performance Improvement offers a model and a wide array of interventions for improving performance which contributes substantively to the goals of the MAQ Initiative. MAQ is a systematic initiative of USAID, CA’s, country partners and other collaborators that seeks to identify and implement practical, cost effective interventions aimed at improving both the access to and quality of family planning and selected reproductive health services.  MAQ has identified a number of interventions, and some examples are the following:  leadership development, client engagement, community engagement, provider rewards/environment, standards/guidelines, organization of work, training, job aids, and so on. 

These MAQ interventions are a subset of the total universe of possible PI interventions. But in applying the PI approach, no intervention would be used until an analysis determined that the intervention would clearly address the problem and was likely to offer significant returns on the time and money invested to carry it out.

11.  What is the relationship between PI and COPE?

COPE stands for "Client Oriented - Provider Efficient", and it is a process and set of tools used to improve the quality of services through self assessment.  The COPE process draws on many principles of QI & PI.  COPE enables supervisors and staff to apply these principles and identify and solve performance problems at a service site level. COPE stresses the definition of good performance, especially in terms of meeting the needs of providers so they can meet the expectations of their clients.

12.  What is the relationship between management and PI?

Management is a multidisciplinary practice that involves the efficient and effective planning, organization, implementation and monitoring and evaluation of inputs, processes, outputs and impacts in support of an organization’s mission, goals and strategies.  The ultimate goal of management is to improve performance in order to achieve better organizational results (e.g., client satisfaction, financial viability, and services to a larger number of clients). Management has long had a performance focus.

Performance Improvement, a systems approach to addressing problems, is one process that managers can use to achieve desired results. Other management methods and tools include organizational assessment, strategic and operational planning, good organizational development practice (team building, more participatory work processes), systems refinement (financial, logistics systems, human resources, quality improvement, planning, MIS, marketing, communication systems, etc.), and leadership and management development.

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